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  1. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42156/psn-pdf
    April 03, 2013 - The effect of a checklist on the quality of post- anaesthesia patient handover: a randomized controlled trial. April 3, 2013 Salzwedel C, Bartz H-J, Kühnelt I, et al. The effect of a checklist on the quality of post-anaesthesia patient handover: a randomized controlled trial. Int J Qual Health Care. 2013;25(2):176…
  2. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/46264/psn-pdf
    August 09, 2017 - Intraoperative handoffs among anesthesia providers increase the incidence of documentation errors for controlled drugs. August 9, 2017 Epstein RH, Dexter F, Gratch DM, et al. Intraoperative Handoffs Among Anesthesia Providers Increase the Incidence of Documentation Errors for Controlled Drugs. Jt Comm J Qual Patie…
  3. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/44409/psn-pdf
    January 22, 2016 - "Anybody on this list that you're more worried about?" Qualitative analysis exploring the functions of questions during end of shift handoffs. January 22, 2016 O'Brien CM, Flanagan ME, Bergman AA, et al. "Anybody on this list that you're more worried about?" Qualitative analysis exploring the functions of question…
  4. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/866203/psn-pdf
    June 26, 2024 - How a major public hospital is protecting doctors by silencing the patients who accuse them. June 26, 2024 Kamb L. NBC News. June 14, 2024, https://psnet.ahrq.gov/issue/how-major-public-hospital-protecting-doctors-silencing-patients-who-accuse- them Transparency is a primary element of an organizational safety cu…
  5. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47595/psn-pdf
    March 06, 2019 - Approaches and Challenges to Electronically Matching Patients' Records Across Providers. March 6, 2019 Washington, DC: United States Government Accountability Office; January 2019. Publication GAO-19-197. https://psnet.ahrq.gov/issue/approaches-and-challenges-electronically-matching-patients-records-across- provid…
  6. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/43942/psn-pdf
    March 11, 2015 - FDA requires label warnings to prohibit sharing of multi- dose diabetes pen devices among patients. March 11, 2015 FDA Safety Communication. Silver Spring, MD: US Food and Drug Administration; February 25, 2015. https://psnet.ahrq.gov/issue/fda-requires-label-warnings-prohibit-sharing-multi-dose-diabetes-pen-device…
  7. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/37770/psn-pdf
    March 10, 2011 - Identifying and quantifying medication errors: evaluation of rapidly discontinued medication orders submitted to a computerized physician order entry system. March 10, 2011 Koppel R, Leonard CE, Localio R, et al. Identifying and quantifying medication errors: evaluation of rapidly discontinued medication orders su…
  8. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/846764/psn-pdf
    March 29, 2023 - Senators threaten consequences after VA confirms 4 deaths tied to computer system tested in Spokane. March 29, 2023 Donovan-Smith O. Spokesman Review. March 15, 2023. https://psnet.ahrq.gov/issue/senators-threaten-consequences-after-va-confirms-4-deaths-tied-computer- system-tested-spokane Implementations of elec…
  9. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/42362/psn-pdf
    July 10, 2013 - How to improve change of shift handovers and collaborative grounding and what role does the electronic patient record system play? Results of a systematic literature review. July 10, 2013 Flemming D, Hübner U. How to improve change of shift handovers and collaborative grounding and what role does the electronic p…
  10. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/41389/psn-pdf
    June 27, 2012 - Can we make postoperative patient handovers safer? A systematic review of the literature. June 27, 2012 Segall N, Bonifacio AS, Schroeder RA, et al. Can we make postoperative patient handovers safer? A systematic review of the literature. Anesth Analg. 2012;115(1):102-15. doi:10.1213/ANE.0b013e318253af4b. https:/…
  11. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/73296/psn-pdf
    May 19, 2021 - AHRQ Safety Program for Methicillin-Resistant Staphylococcus Aureus Prevention. Request for Proposal Comment. May 19, 2021 Agency for Healthcare Research and Quality. May 3, 2021. Fed Register. 2021;86(83):23366-23369. https://psnet.ahrq.gov/issue/ahrq-safety-program-methicillin-resistant-staphylococcus-aureus-pre…
  12. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/837806/psn-pdf
    August 10, 2022 - Do patient engagement IT functionalities influence patient safety outcomes? A study of US hospitals. August 10, 2022 Upadhyay S, Opoku-Agyeman W, Choi S, et al. Do patient engagement IT functionalities influence patient safety outcomes? A study of US hospitals. J Public Health Manag Pract. 2022;28(5):505-512. doi:…
  13. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/45464/psn-pdf
    September 07, 2016 - Measuring adverse events in hospitalized patients: an administrative method for measuring harm. September 7, 2016 Martin J, Benjamin EM, Craver C, et al. Measuring Adverse Events in Hospitalized Patients: An Administrative Method for Measuring Harm. J Patient Saf. 2016;12(3):125-31. doi:10.1097/PTS.000000000000007…
  14. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/72832/psn-pdf
    March 10, 2021 - Communication and Transparency as a Means to Strengthening Workplace Culture During COVID-19. March 10, 2021 Nadkarni A, Levy-Carrick NC, Kroll DS, et al. Communication And Transparency As A Means To Strengthening Workplace Culture During Covid-19. National Academy of Medicine; 2021. doi:10.31478/202103a. https:/…
  15. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/60233/psn-pdf
    April 15, 2020 - Identifying safety hazards associated with intravenous vancomycin through the analysis of patient safety event reports. April 15, 2020 Krukas A, Franklin ES, Bonk C, et al. Identifying safety hazards associated with intravenous vancomycin through the analysis of patient safety event reports. Patient Safety. 2020;2…
  16. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/38064/psn-pdf
    February 23, 2009 - Same system, different outcomes: comparing the transitions from two paper-based systems to the same computerized physician order entry system. February 23, 2009 Niazkhani Z, van der Sijs H, Pirnejad H, et al. Same system, different outcomes: comparing the transitions from two paper-based systems to the same comput…
  17. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/47304/psn-pdf
    October 24, 2018 - Mind the overlap: how system problems contribute to cognitive failure and diagnostic errors. October 24, 2018 Gupta A, Harrod M, Quinn M, et al. Mind the overlap: how system problems contribute to cognitive failure and diagnostic errors. Diagnosis (Berl). 2018;5(3):151-156. doi:10.1515/dx-2018-0014. https://psnet.…
  18. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/39858/psn-pdf
    September 22, 2010 - Problems after discharge and understanding of communication with their primary care physicians (PCPs) among hospitalized seniors: a mixed methods study. September 22, 2010 Arora V, Prochaska ML, Farnan JM, et al. Problems after discharge and understanding of communication with their primary care physicians among h…
  19. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/848085/psn-pdf
    April 26, 2023 - Understanding complexity in a safety critical setting: a systems approach to medication administration. April 26, 2023 Stevens EL, Hulme A, Goode N, et al. Understanding complexity in a safety critical setting: a systems approach to medication administration. Appl Ergon. 2023;110:104000. doi:10.1016/j.apergo.2023.1…
  20. Psn-Pdf (pdf file)

    psnet.ahrq.gov/node/844987/psn-pdf
    February 22, 2023 - Examining medication ordering errors using AHRQ Network of Patient Safety Databases. February 22, 2023 Grauer A, Rosen A, Applebaum JR, et al. Examining medication ordering errors using AHRQ network of patient safety databases. J Am Med Inform Assoc. 2023;30(5):838-845. doi:10.1093/jamia/ocad007. https://psnet.ahr…

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